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SECMON 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site Identilication number. <br />Ile <br />Tracking Sheet to be returned toPublic):Serviceswithin I days •: acceptance •. the <br />.: 1 the disposal or <br />recycling facility.1. permit holder is responsible for ensdring that thisform completed .1/returned. <br />FACUZrY NAME ANASTASIO'S AM/PM MINI MART <br />FACILITYADDRESS:-3425 Tracy Blvd, Tracy, CA <br />TANK ID #39 - I InM ' Tank Description: <br />ss:.::ssss«sssssss:«ssss«ass«:sss:ssss:sssssss«ssss:s:ass:sssssss:ss:sssssss::.:sss:::«asssssss.sss:sssssss <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor. <br />Address: City: Zip: <br />Phone #:( Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank': <br />Tank Decontamination Contractor <br />Phone : <br />• -• ,-• ;.,'1 _ • • • r • �r �r - r- •�, ;r. t �. /-'I /.Y•, 1 r: "/ it r <br />. 11 •' 4/ manner .1 1 1 <br />y Cal EPA. <br />Signature: Title: <br />:ss«:«::sss:s:ssss.:««s«as:sss:assess««ssss:s:::s«:sssssss:ss::ss:s:ss«:«s««:s«:ssss:«ss«««sss:«ssss:ss:s:s <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: <br />Phone #:( <br />Date Tank Received: <br />Signature: Title: <br />s:s:sssssss:s«s:s«:ssss::sss:s::s:::ss::sssssss:::::ssss:ss:s:::ssss:ssss:«ss:sss:ssss:ssss:ssssassssss« <br />EH 23 049 (Revised 7-10-92) page 10' <br />